Chapter 2: Patient Assessment

2.7 Head-to-Toe Assessment: Respiratory Assessment

Critical Thinking Exercises: Questions, Answers, and Sources / References

Critical thinking questions are in bold type, and the answers are italicized. Additional resources or references are provided below.

  1. A client is experiencing mild respiratory distress. Identify two important strategies to address this.
  • Elevate the head of bed (HOB).
  • Encourage the patient to slow down their respiration by being calm and demonstrating slowed respiration.
  • Next would be a more thorough assessment including SpO2 and possible administration of oxygen and/or respiratory related medications.


 2. What potential respiratory issues might the nurse anticipate for the post op patient? Identify an important nursing intervention for each.

Potential Respiratory Issue Post Op

Potential Nursing Intervention

Potential for atelectasis due to inadequate respiratory volume.
  • Deep breathing and coughing
  • Repositioning
  • Elevate head of bed to facilitate lung expansion
Potential for respiratory depression due to opiods.
  • Elevate HOB
  • Assess respiratory rate
  • Administer Naloxone as per agency policy and/or call a Code Blue
Potential for impaired oxygenation (low SpO2) due to medications (sedatives, opioids).
  • Monitor SpO2, respiratory rate (and other vital signs)
  • Administer oxygen as needed
  • Review use of sedatives or opioids, and use sparingly if patient is sensitive to these.

3. Identify two strategies the nurse might implement for the immobile client whose chest sounds reveal decreased air entry to the bases.


A patient who is immobile does not have the advantage of movement, which naturally causes us to breathe deeper thus promotes gas exchange in the lungs.

  • Deep breathing and coughing can promote lung expansion and clearing of any respiratory secretions.
  • Sitting with the HOB elevated promotes lung expansion and better gas exchange at the lung bases.
  • Repositioning can promote movement of any respiratory secretions, which could cause respiratory infection if allowed to remain stagnant.


Taylor, A., DeBoard, Z., & Gauvin, J. (2015). Prevention of postoperative pulmonary complications. Surgical Clinics of North America, 95(2), 237-254.

Sample Learning Activity

The Practical Clinical Skills website has some fun and interesting activities to challenge the learner’s understanding. Faculty members should review the information beforehand to determine appropriateness for the level of the student.

To improve students’ knowledge and skill level with respiratory assessments, I suggest students complete the units on:


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